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Based on review of medical records and facility documents, it was determined that the facility failed to ensure that the patient received a blood transfusion immediately, as prescribed.

Cross Reference:
482.23(c)(4) Nursing Services: Blood Transfusions And IV Medications

Based on one of one medical record reviewed for blood transfusions, staff interview, and review of facility documents, it was determined that the facility failed to ensure that the patient received a blood transfusion immediately, as prescribed.

Findings include:

A review of the medical record for Patient (P) 3 indicated that he/she was admitted to the facility on 10/06/24. P3 has a history of End Stage Renal Disease (ESRD) requiring hemodialysis (HD), and receives dialysis on a schedule of Tuesday, Thursday, and Saturday.

On 10/14/24 at 3:26 PM, a critically low hemoglobin laboratory result of 6.8 g/dL (grams per deciliter), was called to Staff (S)17, the Registered Nurse (RN) caring for P3 at that time. A low hemoglobin level indicates a decrease in red blood cells. A normal hemoglobin range is 12.0-16.0 g/dL.

On 10/14/24 at 3:56 PM, S17 documented a "Nursing Narrative Note" that stated, "... spoke with Dr [doctor] about critical hemoglobin and he/she asked me to notify GI [Gastroenterology] as well as Nephrologist for possible transfusion with dialysis ...".

On 10/14/24 at 7:23 PM, S17 documented a "Nursing Narrative Note" that stated, "... hematologist saw the patient and is trying to get consent for blood transfusion ...".

A "Progress Note" dated for the following day, 10/15/24 at 7:04 AM, documented by the physician stated, " ...Blood work showed hemoglobin to be extremely low patient to have blood transfusion today."

Twenty hours and 53 minutes after the RN was notified of the critically low hemoglobin result, at 12:19 PM on 10/15/24, a physician's order was placed to, "TRANSFUSE Red Blood Cells ...Priority Stat [immediately]..."

Approximately five hours after the order was placed, on 10/15/24 at 5:14 PM, a "Progress Note" documented by the Hematologist stated, "... 10/15 pt [patient] seen in follow up for PRBC [packed red blood cell] transfusion ... Pt for PRBC transfusion, discussed with son about consent Follow cbc [complete blood count] ...".

On 10/16/24 at 2:29 AM, a "Nursing Narrative Note" documented by S16, the RN caring for P3 at that time, stated, ".... Pt also has uncompleted blood transfusion orders from the day. I contacted blood bank to prepare the unit per order. Consent, copy of the order and requisition forms faxed to blood bank. Pending receipt of blood to initiate transfusion. Pt v/s [vital signs] within normal limits. Pt is in no acute distress at this time ..."

On 10/16/24 at 4:49 AM, P3 received their ordered blood transfusion, 16 hours and 30 minutes after the transfusion was ordered. This was also one day, 13 hours, and 23 minutes after the RN was notified of the critically low hemoglobin results.

The above findings were discussed in an interview at 11:04 AM, with S15, Chief Medical Officer (CMO). S15 stated that he/she agrees that there was a "delay of care in terms of communication."

Facility policy titled, "Administration of Blood and Blood Components," revised 06/06/23, stated, "... Procedure ... Blood must be administered as soon as possible and within 30 minutes of release from Blood Bank. ..."

Based on medical records review and review of facility documents, it was determined that the facility failed to ensure that patients are transferred to another facility within the expected time frame of the discharge plan when hemodialysis (HD) services are not able to be provided.

Cross Reference:
482.43(a)(1) Discharge Planning: Timely Evaluation

Based on one of four medical record reviewed, staff interview, and review of facility documents, it was determined the facility failed to ensure that patients are transferred to another facility within the expected timeframe of the discharge plan when hemodialysis (HD) services are not able to be provided.

Findings include:

On 10/23/24 at 10:37 AM, a review of Patient (P) 3's medical record revealed the following:

P3 was admitted on 10/06/24 at 3:54 AM. P3 had a past medical history of End Stage Renal Disease (ESRD) requiring HD treatments on a schedule of Tuesday, Thursday, and Saturdays. While admitted to the facility, P3 received dialysis treatments regularly until Tuesday 10/15/24, when the facility went on dialysis divert.

On 10/15/24 at 3:10 PM, a "Nursing Narrative Note" documented by Staff (S) 17, a Registered Nurse (RN) stated, "... Dialysis held today for RO [Reverse Osmosis] out of service MD [Medical Doctor] made aware ..."

At 4:11 PM, a "Nursing Narrative Note" documented by S17 stated, "... report called to RN at [receiving facility] at 04:11 PM ..."

On 10/16/24 at 2:29 AM, a "Nursing Narrative Note" made by S16, the RN caring for P3 at that time stated, "... I was informed during handoff that pt [patient] had been discharge and was just waiting to be picked up by transportation to [receiving facility] due to dialysis diversion at [current facility] by AM [morning] RN, [S17]. Pt however had no discharge orders placed, this writer attempted to call attending [physician name] multiple times to secure an order for discharge but my calls were unanswered. Nursing supervisor aware ... Pt v/s [vital signs] within normal limits. Pt is in no acute distress at this time ..."

On 10/16/24 at 11:20 AM, P3 was transferred to a different facility capable of providing HD services.

The above findings were discussed during an interview on 10/23/24 at 11:04 AM, with S15, Chief Medical Officer (CMO). S15 stated that the Hospitalist who is on the facility's campus at all times would have been able to discharge the patient. S15 stated that he/she agreed that there was a delay of care in terms of communication. Per S15, the process for escalation in the event staff is unable to reach the attending is to attempt to reach out to the medical staff in the following order: 1. Attending, 2. Hospitalist, 3. Tele Intensivist, 4. Physician Advisor, 5. CMO. S15 stated that his/her personal number is posted on each unit. S15 stated that at the time of the interview he/she was unable to get in contact with the nursing supervisor to ask if the event was escalated. S15 confirmed that the event was not escalated to him/her. S15 stated that he/she called the attending physician for P3 and found that the attending physician stated he/she did not receive any calls. The attending did not realize he/she needed to place discharge orders because he/she had told the staff on 10/15/24 that the patient was being transferred and contacted the receiving facility personally.

Due to the dialysis divert and the delay in receiving discharge orders from a physician, P3 did not receive dialysis on their scheduled day of 10/15/24.

The facility provided a document on 10/23/24 at 3:00 PM titled, "Medical Staff Rules and Regulations" that stated, "Patients shall be discharge only upon order of the attending physician ...".